Long hospital wait times can be deadly

Tackling treatment delays is vital as health-system pressures mount

This is the first in a two-part series on health-care wait times. Coming Thursday: Why the health-care system needs mystery shoppers.

SAN FRANCISCO (MarketWatch) — Need health care? You might have to take a number.

If you have private, job-based health insurance and need follow-up care for an existing condition, you likely won’t face delays getting in to see a doctor. But no matter what kind of insurance coverage you have, if you have a new health problem or an emergency requiring a hospital or operating room, you may have to wait — dangerously long, in some cases — to be treated.

“Timely access to care is an enormous challenge for our health-care system,” said Dr. Arthur Kellermann, director of Rand Health in Santa Monica, Calif., and an emergency doctor for 20 years. “It’s especially an issue after-hours, nights and weekends.”

“The scheduled follow-up for the average person with private health insurance — we do that OK,” he said. “But the ‘Oh my God, what could this be? I need to see someone’ or ‘I’ve been given a possible diagnosis that’s terrifying,’ we as a system do handle that very poorly, despite the money we’re spending on health care, because we have capacity challenges and challenges getting that person in for an unscheduled visit.”

The stakes are getting higher as the population ages and the major features of the health-reform law start to kick in. In 2014, more than 30 million uninsured Americans are set to become newly insured through an expanded Medicaid program, new health-insurance marketplaces and tighter regulations on health plans. The government also is pressing for higher quality for the amount of money it spends on health care. Total spending in the U.S. comes to $2.5 trillion every year, or about 17% of gross domestic product.

Medical delays can be deadly

Dr. John Maa, an assistant professor of surgery and director of the surgical hospitalist program at University of California at San Francisco, knows the pain health-care bottlenecks can inflict, even in places designed to expect the unexpected.

Courtesy of John Maa

Dr. John Maa and his mother, Laura Maa.

Two and a half years ago, his relatively healthy 69-year-old mother went to a California emergency room with an irregular heartbeat, Maa wrote in the June 15 edition of the New England Journal of Medicine (NEJM).

She arrived on a Thursday evening but wasn’t admitted to the hospital until the next day because there was no inpatient bed available for her. Doctors gave her an anti-clotting drug and informed her that due to the delay, she would have to wait until Monday to get the procedures she needed. The following day, Dr. Maa’s mother had a massive stroke. She had emergency surgery, but she died.

“Politicians decry lengthy waiting times for elective procedures in Britain, Canada and other countries,” Maa wrote in the NEJM. “A lengthy wait for elective surgery can be irritating, but it is rarely deadly.”

The waits that matter are for the emergency treatment of traumatic injuries, heart attack, cardiac arrest and deadly infections, he wrote.

“Those of us who have dedicated our lives to health care must confront the fact that our inability (or, more likely, unwillingness) to reduce the waits and delays that bedevil emergency care is harming and even killing our patients,” he continued. Read his published perspective.

More patients will pressure system

In a recent interview, Maa said he was optimistic the system could be improved, but he worries that things may get worse before they get better with the expected influx of newly insured patients from the health overhaul in 2014. He sees a growing number of hospitals advertising short ER wait times as a hopeful sign of healthy market competition.

But among the mounting pressures, he said, are doctors demanding extra payment for being on call and hospitals prioritizing lucrative elective surgery while failing to reserve enough surgery suites for emergency patients.

The U.S. needs to better understand its emergency-care problems and economics, Maa said. After visiting about 50 emergency rooms, he has a few ideas for improving the process.

Hospitals could post a modern “no vacancy” sign alerting prospective patients if the hospital has to send patients elsewhere or “board” them on gurneys because of long waits. In such cases, those with the luxury of time could choose another ER.

“Hospitals should post online and on Twitter when they’re diverting ambulances or boarding patients,” he said. “They should be required to let patients know if you come to our ER, you’re probably going to wait…. I’ve seen patients who’ve spent their entire hospital stay in the emergency room.”

A visit to another notoriously inconvenient place gave him added inspiration. Shortly after his mother died, Maa lost his driver’s license. He made an online reservation with the Department of Motor Vehicles and braced himself for the worst. Instead, he came away impressed with that agency’s ability to triage.

“I expected to wait hours. It only took 40 minutes,” Maa said. “I think there are great lessons hospitals can learn from the DMV.”

Match prices to services

His second idea for improving ERs aims for the financial jugular: Cut Medicare Part A hospital reimbursement for patients who are boarded.

“My mom, on her hospital bill, was billed the same rate as if she were upstairs in a regular bed,” Maa said. “I don’t think it’s right that hospitals get paid the same whether you’re lying on a gurney in a crowded hallway or in a hospital bed.”

Maa offered an analogy for his mother’s care: “Say you had a reservation at a hotel. You get there and they say, ‘We’re really sorry — we gave your room away. Here’s a pillow and a blanket. We’ll charge you to sleep in the lobby.’”

Many experts agree that reducing the number of people who go to the emergency room when they could receive the same care in a regular doctor’s office would help cut ER wait times. But that’s not as straightforward as it might seem.

Patients on Medicaid, the government health program for the poor, visit the ER more often than other groups, but that’s because doctors often reject their insurance, ask them for payment they can’t afford or refer them to the ER in the first place, Kellermann said.

“We’re blaming people for doing what the health-care system tells them to do,” he said.

Not solely emergency rooms

Potentially long waits for health care extend beyond emergency rooms.

In a nod to the problem, Cancer Treatment Centers of America, a for-profit network of cancer hospitals, recently announced a program where patients with four common cancer types can get a fixed-price diagnosis and treatment plan within five business days. If CTCA fails to deliver in that time frame, it will absorb the cost of any additional services. The company’s move may put pressure on other cancer-treatment facilities to match or beat its expedience in completing an array of imaging tests and patient consultations. Read more: Making cancer treatment less onerous for patients.

“There is pretty substantial evidence that delays getting to cancer diagnosis or treatment clearly affect patients’ outcomes. It’s not a good thing,” Kellermann said. “It’s unconscionable to have a biopsy, diagnosis and not be able to get into treatment.”

Delays for pressing needs like cancer care shouldn’t be tolerated, but specific data on wait times is hard to come by, he said.

“What we don’t have data on is how difficult is it for Americans from different population groups, different coverages to get timely care for their condition?”

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